Paradoxical enlargement of lymph nodes during therapy of central nervous system tuberculosis.

Paradoxical response (PR) to appropriate anti-TB therapy is encountered mainly in lymph nodes, brain and lungs. It is well documented in lymph nodes, with some series quoting an incidence of 30%, whereas in the brain, PR incidence has been reported to occur at a lesser degree. In a recent publication of a small series of CNS tuberculoma, PR occurred in 16% of the patients. In pulmonary TB, the paradoxical reaction is rarely observed, and it takes the form of respiratory distress syndrome. The prolonged fever occasionally seen in an otherwise satisfactory response to anti-TB may be another manifestation of PR. Other tissues or organs in the human body may be affected by PR, but this has not yet been documented. All the reactions described involve the initial site of the disease manifestation. We report a case of TB meningitis with cerebral and spinal tuberculomas, in which the PR affected the lymph nodes and not the CNS. Our purpose is to document this unique reaction and discuss its significance and possible mechanism.